Abstract and Introduction
Abstract
Introduction: Illicit drug use is a serious public health problem associated with significant co-occurring medical disorders, mental disorders, and social problems. Yet most individuals with drug use disorders have never been treated, though they often seek medical treatment in primary care. The purpose of this study was to examine the baseline characteristics of people presenting in primary care with a range of problem drug use severity to identify their clinical needs.
Methods: We examined sociodemographic characteristics, medical and psychiatric comorbidities, drug use severity, social and legal problems, and service utilization for 868 patients with drug problems. These patients were recruited from primary care clinics in a medical safety net setting. Based on Drug Abuse Screening Test results, individuals were categorized as having low, intermediate, or substantial/severe drug use severity.
Results: Patients with substantial/severe drug use severity had serious drug use (opiates, stimulants, sedatives, intravenous drugs); high levels of homelessness (50%), psychiatric comorbidity (69%), and arrests for serious crimes (24%); and frequent use of expensive emergency department and inpatient hospitals. Patients with low drug use severity were primarily users of marijuana, with little reported use of other drugs, less psychiatric comorbidity, and more stable lifestyles. Patients with intermediate drug use severity fell in between the substantial/severe and low drug use severity subgroups on most variables.
Conclusions: Patients with the highest drug use severity are likely to require specialized psychiatric and substance abuse care, in addition to ongoing medical care that is equipped to address the consequences of severe/substantial drug use, including intravenous drug use. Because of their milder symptoms, patients with low drug use severity may benefit from a collaborative care model that integrates psychiatric and substance abuse care in the primary care setting. Patients with intermediate drug use severity may benefit from selective application of interventions suggested for patients with the highest and lowest drug use severity. Primary care safety net clinics are in a key position to serve patients with problem drug use by developing a range of responses that are locally effective and that may also inform national efforts to establish patient-centered medical homes and to implement the Affordable Care Act.
Introduction
Illicit drug use is a serious public health problem with a large economic impact. There is high comorbidity between drug use disorders and both medical and mental health disorders, and drug use is commonly associated with a host of social problems such as homelessness, criminal justice involvement, and unemployment. Despite this substantial disability and comorbidity, most individuals with drug use disorders have never been treated. This finding underscores the importance of the detection and referral roles of primary care physicians in the treatment of individuals with substance use disorders, who are often seen in primary care because of their heightened prevalence of medical conditions.
The Affordable Care Act (ACA) has established a number of mechanisms designed to promote person-centered care. These changes greatly expand the responsibilities of primary care providers, especially given the ACA's expectations for better outcomes and reduced costs for those with comorbid conditions. Yet very little is known about individuals with problem drug use who present in primary care; most information about this population comes from national surveys, studies of treatment-seeking populations, or studies conducted in emergency departments (EDs).
To address this gap, this study was designed to take advantage of a randomized controlled trial that examined the impact of a brief intervention for people with problem drug use in a safety-net primary care setting, where patients with socioeconomic disadvantage often associated with drug use may be seen. Our goal was to examine baseline characteristics of the 868 patients with problem drug use to identify their clinical needs. This information can serve as a guidepost for primary care physicians who must perform a rapid needs assessment of patients they serve and determine how to use the limited resources that they might have.